Best Treatment for Croup
Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose to all children with croup regardless of severity, and add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) only for moderate to severe cases with stridor at rest or significant respiratory distress. 1
Initial Assessment
When evaluating a child with suspected croup, immediately assess for:
- Stridor at rest (indicates moderate-to-severe disease) 1
- Accessory muscle use, tracheal tug, intercostal/subcostal retractions 2
- Oxygen saturation (hypoxemia if <92-93%) 1, 3
- Respiratory rate (>70 breaths/min warrants admission) 1
- Level of agitation (may indicate hypoxia requiring oxygen) 3
Radiographic studies are unnecessary and should be avoided unless you suspect an alternative diagnosis like bacterial tracheitis or foreign body aspiration. 1, 2
Treatment Algorithm by Severity
Mild Croup (No Stridor at Rest)
- Oral dexamethasone alone is sufficient 1
- Dose: 0.15-0.6 mg/kg (maximum 10-12 mg) as a single dose 1
- Alternative: Prednisolone 1.0-2.0 mg/kg (maximum 40 mg) if dexamethasone unavailable 3
Moderate to Severe Croup (Stridor at Rest, Respiratory Distress)
- Give oral dexamethasone immediately (same dosing as above) 1, 3
- Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 2
- Administer oxygen via nasal cannula, head box, or face mask to maintain saturation ≥94% 2, 3
- Observe for at least 2 hours after the last epinephrine dose to monitor for rebound symptoms 3
The effect of nebulized epinephrine is short-lived, lasting only 1-2 hours, which is why extended observation is critical. 3
Alternative Corticosteroid Option
Nebulized budesonide 2 mg is equally effective as oral dexamethasone and may be used when oral administration is not feasible (e.g., severe vomiting, inability to swallow). 1
Hospitalization Criteria
Consider admission when:
- ≥3 doses of nebulized epinephrine are required (the "3 is the new 2" approach reduces unnecessary admissions by 37% without increasing revisits) 1, 2
- Oxygen saturation <92% 1
- Age <18 months 1, 3
- Respiratory rate >70 breaths/min 1
- Persistent difficulty breathing despite treatment 1
The updated guideline from the American Academy of Pediatrics recommends waiting until 3 doses of epinephrine before admission rather than the traditional 2 doses, which significantly reduces hospitalization rates without compromising safety. 1
Critical Pitfalls to Avoid
- Never discharge a patient within 2 hours of nebulized epinephrine administration due to risk of rebound airway obstruction 1, 3
- Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 2
- Do not skip corticosteroids in mild cases—they benefit all severity levels 1
- Avoid admitting after only 1-2 doses of epinephrine when a third dose could be safely administered in the emergency department 1
- Do not use antibiotics routinely—croup is viral and antibiotics are ineffective 1
- Do not rely on cold air or humidified air treatments—these lack evidence of benefit 1, 3
- Do not give over-the-counter cough medicines—they have no proven benefit and can cause harm 1
Discharge Criteria
Send the child home when:
- Stridor at rest has resolved 1
- Minimal or no respiratory distress 1
- Adequate oral intake 1
- Parents can recognize worsening symptoms and know to return if needed 1, 3
Instruct parents to follow up with their general practitioner if the child deteriorates or does not improve after 48 hours. 1, 3
When Standard Treatment Fails
If a child fails to respond to 3 doses of racemic epinephrine, consider alternative diagnoses:
- Bacterial tracheitis 2, 3
- Foreign body aspiration 2, 3
- Epiglottitis 3
- Retropharyngeal or peritonsillar abscess 3
Direct visualization by laryngoscopy is the most important investigation to rule out these croup-mimicking conditions when standard treatment fails. 2